CTA with fluoroscopy image fusion guidance in endovascular complex aortic aneurysm repair.

OBJECTIVES: To evaluate the effect of intraoperative guidance by means of live fluoroscopy image fusion with computed tomography angiography (CTA) on iodinated contrast material volume, procedure time, and fluoroscopy time in endovascular thoraco-abdominal aortic repair. METHODS: CTA with fluoroscopy image fusion road-mapping was prospectively evaluated in patients with complex aortic aneurysms who underwent fenestrated and/or branched endovascular repair (FEVAR/BEVAR). Total iodinated contrast material volume, overall procedure time, and fluoroscopy time were compared between the fusion group (n = 31) and case controls (n = 31). Reasons for potential fusion image inaccuracy were analyzed. RESULTS: Fusion imaging was feasible in all patients. Fusion image road-mapping was used for navigation and positioning of the devices and catheter guidance during access to target vessels. Iodinated contrast material volume and procedure time were significantly lower in the fusion group than in case controls (159 mL [95% CI 132-186 mL] vs. 199 mL [95% CI 170-229 mL], p = .037 and 5.2 hours [95% CI 4.5-5.9 hours] vs. 6.3 hours (95% CI 5.4-7.2 hours), p = .022). No significant differences in fluoroscopy time were observed (p = .38). Respiration-related vessel displacement, vessel elongation, and displacement by stiff devices as well as patient movement were identified as reasons for fusion image inaccuracy. CONCLUSION: Image fusion guidance provides added value in complex endovascular interventions. The technology significantly reduces iodinated contrast material dose and procedure time.

Introduction of advanced laparoscopy for peritoneal dialysis catheter placement and the outcome in a University Hospital.

BACKGROUND: Peritoneal dialysis (PD) catheters can be obstructed by omental wrapping or migration, leading to catheter malfunction. Multiple catheter placement techniques have been described. Advanced laparoscopy with fixation of the catheter and omentum has been reported to improve functional outcome compared to basic laparoscopy without fixation. This feasibility study describes surgical technique, complications, and comparison of the functional outcome of advanced versus basic laparoscopic catheter placement. METHODS: Between July 2016 and April 2019, the advanced laparoscopy technique was applied in all eligible patients. Two experienced surgeons placed the catheters in a standardized procedure. Peri-operative complications and functional outcome of the catheter were scored. Results were compared to a historical cohort retrieved from our RCT performed earlier using basic laparoscopy. FINDINGS: The basic laparoscopic group (BLG) consisted of 46 patients and the advanced laparoscopic group (ALG) of 32. Complication rate in both groups was similar and low with 7% in the BLG and 6% in the ALG (p = 1.0). There was a trend toward better functional catheter outcome in the ALG (88%) compared to the BLG (70%) (p = 0.1). Part of the catheter failures in the ALG could be related to the learning curve. After revision surgery, 94% of patients in the ALG had a functional catheter. These findings lead to the set-up of a multi-center randomized-controlled trial, currently running, comparing basic to advanced laparoscopic techniques.

Heterotopic ossifications in midline abdominal scars: a critical review of the literature.

Heterotopic ossification (HO) is the formation of bone outside the skeletal system, including old incisions. Although a well-known complication after orthopaedic surgery, it is still considered an uncommon phenomenon after vascular surgery. Recent data, however, show that up to 25% of all patients develop HO after midline abdominal surgery. In this article, we present the case of a symptomatic HO, 7 years after an aortobiiliac prosthetic reconstruction for an abdominal aortic aneurysm. Furthermore, we review current insights into the aetiology and show bone morphogenetic proteins to play a crucial role. Treatment options are also reviewed, but lacking any supportive evidence for other therapies, surgical excision with primary closure is the treatment of choice.

Open repair for ruptured abdominal aortic aneurysm and the risk of spinal cord ischemia: review of the literature and risk-factor analysis.

OBJECTIVES: Spinal cord ischemia after open surgical repair for rAAA is a rare event. We estimated the current incidence and tried to identify risk factors. We also report a new case. METHODS: Group A consisted of 10 reports on open repair for rAAA from 1980 until 2009. Only series of ≥100 patients were considered to estimate the incidence. Thirty three case reports from 1956 until 2009 were identified (group B). Case reports from group B were not encountered in group A. Group B patients were stratified according to the type of neurological deficit as described by Gloviczki (type I complete infarction and type II infarction of the anterior two third). RESULTS: Group A consisted of 1438 patients. In group A 86% were male with a mean age of 72.1 years. The incidence of post-operative paraplegia was 1.2% (range 0-2.8%). In-hospital mortality was 46.9%. Of the 33 patients of group B were 86% male with a mean age of 68.0 years. Most patients developed a type I (42%) or type II (33%) deficit. In-hospital mortality was 51.6%. No significant differences between different types were encountered. CONCLUSION: Spinal cord ischemia after ruptured AAA is a rare complication with an incidence of 1.2% (range 0-2.8%).

Strategies to prevent spinal cord ischemia in thoracoabdominal aortic aneurysm repair.

Spinal cord ischemia (SCI) after thoracic and thoracoabdominal aortic aneurysm repair is a devastating complication, which happens after both open and endovascular repair. Incidence of SCI varies widely in the literature. Many factors during preoperative, operative and postoperative phases influence this incidence. The purpose of this article was to provide an overview on all factors influencing SCI and to report on the evidence in the literature about how to prevent SCI.

Contemporary management of the demanding infra-renal neck in abdominal aortic aneurysm repair.

Proximal infrarenal neck anatomy is a crucial factor in determining outcome of abdominal aortic aneurysm (AAA) repair. Unfavorable or demanding infrarenal neck anatomy significantly increases the complexity of both standard endovascular and open repair resulting in increased rates of morbidity and mortality. While technological improvements and expanding institutional experience have resulted in an increased proportion of patients with an AAA with unfavorable infrarenal neck treated by (fenestrated) endovascular techniques, open repair has also remained a valid technique. The purpose of this manuscript was to describe the wide array of endovascular and open techniques in use to treat patients with an AAA with a demanding infrarenal neck and discuss their results and indications.

[Aortocoronary bypass surgery; at least 6 months follow-up required for assessment of postoperative course]. / Aortocoronaire bypasschirurgie: voor oordeel over postoperatief beloop follow-up nodig gedurende tenminste een halfjaar.

OBJECTIVE: To determine how the mortality and morbidity after aortocoronary bypass surgery during the hospital stay correspond with those in the first 6 months after the operation. DESIGN: Prospective and retrospective. METHOD: Data of 563 patients undergoing isolated myocardial revascularization in 1998 in the Academic Hospital Nijmegen, the Netherlands, were collected on mortality and morbidity 180 days after the operation. The Parsonnet score was used to assess the operative risk of the patients. RESULTS: The patient group consisted of 422 males and 141 females, with a mean age of 64.3 years. The median Parsonnet score was 6 (range: 0-50). The mean hospital stay was 7.9 days (SD: 9.4). The hospital mortality was 3.9% (22/563). The follow-up was 100%. During the follow-up 11 patients died, 10 from cardiac causes. Six months postoperatively the mortality was 5.9% (22/563). The Kaplan-Meier curve of the survival probability rate showed a persistent decrease, mainly in the higher risk patients. Non-fatal cardiovascular events were registered in 9.6% of the surviving patients (51/530). CONCLUSION: The hospital mortality and morbidity after aortocoronary bypass surgery were considerably lower than the total postoperative mortality and morbidity during the first 6 months after the operation. For assessment of the postoperative course, systematic follow-up over 6 months is necessary.

The current endovascular therapeutic spectrum for short neck and juxtarenal aneurysms.

Endovascular treatment of short neck infrarenal and juxtarenal abdominal aortic aneurysms (AAA) is feasible. Many different techniques have been used, including standard stent-grafts with or without adjuncts as endoanchors or chimney grafts, fenestrated stent-grafts or even newer concepts like the multilayer flow modulating stent. The purpose of this article was to describe the techniques, the indications and results of the various endovascular methods to treat short neck infrarenal and juxtarenal AAA.

Spinal cord function monitoring during endovascular treatment of thoracoabdominal aneurysms: implications for staged procedures.

AIM: Spinal cord ischemia is a well-known complication in the treatment of thoracoabdominal aneurysms (TAAA). Despite the fact that endovascular treatment of TAAA is less invasive, spinal cord ischemia rate is not reduced if compared to open repair. METHODS: We report the results of our experience of spinal cord function monitoring by measuring motor evoked potentials (MEP) during endovascular treatment of TAAA type II and III. Depending on the level of the MEPs the decision is made whether to stage the procedure or not. We treated ten patients according to this protocol. RESULTS: In two patients, MEPs decreased 50% or more and procedures were staged. Both experienced no neurological complications after first and second procedure. No MEPs decrease was seen during the second procedures. One of the other eight patients had a temporary right lower leg pararesis. CONCLUSION: In conclusion we state that our first experience demonstrates the value of assessing spinal cord function during extensive endovascular TAAA repair with subsequent strategies to prevent paraplegia.

Visceral artery aneurysms.

Visceral artery aneurysms (VAAs) are a rare condition, in case of a rupture they have a high mortality rate up to 70%. Visceral artery aneurysms are seen more often these days with the more widespread use of computed tomography and angiography. There are various options for treating VAAs; open surgical repair, endovascular treatment, and laparoscopic surgery. We report 5 cases of visceral aneurysms, all treated differently--ligation, aneurysmectomy (with splenectomy), emergency and elective coil embolization, and conservatively. We will further give a review of the literature on etiology, diagnosis, and treatment options.